Provider Demographics
NPI:1386920585
Name:ENDICOTT, LANNY RAY (LCSW, LMFT)
Entity type:Individual
Prefix:DR
First Name:LANNY
Middle Name:RAY
Last Name:ENDICOTT
Suffix:
Gender:M
Credentials:LCSW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 E 58TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-8401
Mailing Address - Country:US
Mailing Address - Phone:918-742-5597
Mailing Address - Fax:918-742-4485
Practice Address - Street 1:3631 S ELM PL
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74011-1856
Practice Address - Country:US
Practice Address - Phone:918-557-8789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-01
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKLMFT 328101YM0800X
OKLCSW 296101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health